Healthcare Provider Details

I. General information

NPI: 1053370148
Provider Name (Legal Business Name): MR. TIMOTHY G WAKSMONSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MOHEGAN AVE
NEW LONDON CT
06320-8100
US

IV. Provider business mailing address

1538 ROUTE 12 UNIT 7
GALES FERRY CT
06335-1845
US

V. Phone/Fax

Practice location:
  • Phone: 860-444-8408
  • Fax: 860-444-8413
Mailing address:
  • Phone: 860-444-8408
  • Fax: 860-444-8413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number24720000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: